ADDIS ABABA, Ethiopia — Twenty-year-old Michot Sebresilassei fled her home country of Eritrea in 1998 during the war with Ethiopia. She wound up in Addis Ababa, Ethiopia's capital, where she was employed as a maid until she became too weak to do any work. Skinny and wrapped in a white shawl, she sits in government-subsidized, one-room home and says her hope is to regain strength and get a job, "anything I can find."
Almaz Bishaw, 29, was also displaced from her home, not by war but by her neighbors and landlords, who forced her out by raising the rent when they found out about her sickness. She now lives with her younger brother in a rickety shack made of wood sticks and plastic in the outskirts of Addis Ababa.
Although Sebresilassei and Bishaw don't know each other, their lives are linked by more than just being young, female and displaced — both are infected with HIV. Sebresilassei got the virus when she was raped by soldiers as she escaped her war-wrecked country. Bishaw was infected by a boyfriend she no longer dates.
In the past, both women would have been among the estimated 130,000 adults and children to die of AIDS in Ethiopia in 2005 alone. But Sebresilassei and Bishaw are surviving with the help of antiretroviral drugs — a therapy that fights the HIV virus — that they get through the President's Emergency Plan for AIDS Relief. PEPFAR is a five-year, $15 billion initiative to battle HIV/AIDS in Africa, the Caribbean, Guyana and Vietnam through treatment, prevention and care programs.
PEPFAR has been criticized for originally using only brand-name medicines that have been approved by the Federal Drug Administration as opposed to more affordable generic drugs. Its support of HIV treatment in countries like Ethiopia, however, has been praised by many, including former President Bill Clinton. The program, which now includes about two dozen generic formulations that were approved through an FDA fast-track process, expects to treat 2 million people by 2008.
But launching a major treatment program in countries with weak public health systems, structural poverty and lack of basic infrastructure is not an easy commitment. In visits to hospital and clinics in urban and rural areas of Ethiopia, ICIJ found many obstacles for those trying to deliver and access the drugs, among them lack of transportation to get to the hospitals; absence of a system that can help track patients; and persistent hunger.
PEPFAR-funded groups such as Johns Hopkins and Columbia universities are training nurses and doctors, and upgrading laboratories and pharmacies. Another U.S. nongovernmental organization, Family Health International, has improved the capacity of the health centers so they can absorb part of the demand for HIV treatment. But the process is slow in a country like Ethiopia where the government spends just US$12 per capita annually in health care. The eastern Africa countries of Mozambique and Kenya spend double that amount.
About 47,000 Ethiopians are now on antiretroviral treatment paid for by the U.S. government. The target for 2008 is 250,000.
Progress called 'a miracle'
The progress seems modest, especially when compared with that of other PEPFAR countries, but those working in the field see it differently. "What has happened in Ethiopia is a miracle," said Gabriel Daniel, a senior program associate with Management Sciences for Health, a U.S. nonprofit group funded by PEPFAR to ensure that HIV drugs are delivered, stored and managed properly.
"Before these resources became available, people were buying drugs in the black market and selling their cows to get the pills," said Daniel, who is Ethiopian. Prior to PEPFAR, Ethiopia never had a free HIV treatment program. Only a minority of patients, mostly men, could afford the drugs — and many of them dropped the treatment and died when they ran out of money. Others resorted to a belief deeply entrenched among the Ethiopian Orthodox Church followers — the curative power of holy water.
PEPFAR treatment started in Zewditu Hospital, one of the largest in Addis Ababa, in early 2005. Today the hospital is overflowing with 4,500 people receiving HIV treatment and an average of 150 patients added to the list every month.
"We are struggling," said Dr. Tizeta Gossa, head of the hospital, as she outlined the difficulties faced in delivering the treatment. Crowded laboratories and lack of basic medical devices in the HIV unit are some of the most salient examples. She said patients have died rushing from the antiretroviral treatment room to the emergency room, the only area where defibrillators are available.
"We don't have anything, but that doesn't mean that people are not getting the service," she said. "We are trying."
Gossa showed the sketch of a new HIV compound she is expecting to build with the help of Johns Hopkins University, and which will integrate all the HIV services in one building. "This is our dream," Gossa said, her deep voice breaking. "I was about to give up, but I said no."
'Don't just hand [out] drugs'
Problems multiply as one travels away from the capital city and other urban centers. In Shashemenē General Hospital, about 125 miles south of Addis Ababa, there is no laboratory infrastructure to support antiretroviral treatment, so doctors are sending the lab samples to another hospital. They also lack refrigerators to store the drugs, so they use ice.
"I am frustrated," said the hospital's acting director, Melese Taye, a 24-year-old physician. Columbia University is helping the hospital implement the program for which two physicians and two nurses have been trained. Taye said that in May 120 patients were on HIV treatment and that 15 children were receiving pediatric drugs.
In the countryside, basic needs such as transportation are a big obstacle to treatment. "They don't have transportation to come here. They ask us for help, but we can't help," Taye said, walking along one of the compound's internal dirt paths. A leprosy unit is still active in Shashemenē Hospital.
Most hospitals and clinics don't have a system to track down patients who drop out of treatment. In Zewditu Hospital, 15 percent of the patients miss appointments or abandon the treatment. In Āsela Hospital, a facility south of Addis Ababa that serves an area of 3 million people, doctors have resorted to community networks. They organize patients to look after one another and help locate those who miss appointments. Medical director Deste Garoma said the system was working well and so far "very few" patients had abandoned the therapy.
Recently, the Ethiopian government launched a public health program designed to train more than 30,000 health extension workers and deploy them in villages around the country. PEPFAR is helping to fund the initiative and U.S. government officials said they expect the health workers will play a crucial role in bringing people back to HIV therapy.
One of the reasons patients abandon treatment in Ethiopia, doctors say, is that they can't afford the balanced diet that the drugs require. A tall man who speaks perfect Spanish because he was trained in Cuba, Garoma said hunger is the biggest concern among the 500 patients that were receiving PEPFAR-supported antiretroviral treatment in Āsela Hospital in May. "They ask us for food," he said. "What we do is send them to the church to see if they can help them."
Six to 13 million Ethiopians have shortages of food in their households, according to the World Food Programme.
Melissa Jones, a U.S. Agency for International Development official in Ethiopia, said PEPFAR's goal is to provide "quality [antiretroviral] services" and that includes addressing issues of malnutrition. Currently, the World Food Programme is receiving PEPFAR and USAID funds to feed 110,000 HIV patients in urban areas around the country.
For Sileshi Betelei, executive director of Dawn of Hope, an association of HIV-positive people, the key to a successful antiretroviral program in Ethiopia is to provide patients with work skills, help them find jobs and empower them to fight discrimination. "We tell them [donors]: Don't just hand [out] drugs," Betelei said.
Others worry about the future. They wonder whether the United States is building the public health program so that it can be sustained locally after foreign funding stops.
"Doctors … feel that if the programs are run by Americans for Americans in an American way, it isn't going to last," said Tatiana Shoumilina, UNAIDS Monitoring and Evaluation adviser in Ethiopia.
Daniel, the Management Sciences for Health official, said concerns about sustainability are legitimate. "You can't blame them," he said in an interview in Zewditu Hospital, where his agency has improved the pharmacy and built individual booths to protect patients' privacy when they pick up their medicines. He says that the Ethiopian government, and ultimately the Ethiopian people, own the programs his organization is helping implement. "But the way the [Ethiopian] government does business, you can't get things done," he added. "So you have to come and lead them."
The directors of the Zewditu and Āsela hospitals, Gossa and Garoma, said the Ethiopian government should step up to assure the continuity of the program. "Bush's help can't last forever," said Garoma. "Our own government should build capacity to continue this program."
Shoumilina said a combination of a sense of urgency and long-term vision is needed. "Yes, there is a sense of urgency. Yes, I have helped 15 people today, what about 115 tomorrow? Who is going to help them? What did I do?"
The night falls almost abruptly in Āsela, and it's raining outside. Inside the hospital, a timid light illuminates the hallways but the rooms are dark. A skinny woman sits on her bed, her head covered with a red scarf, her eyes fixed in the wall.
"There are more HIV cases in this area than we imagine," said Garoma, opening the door to the nurses' station, where inpatients' medicines were neatly arranged in small, individual containers, ready to be delivered to their rooms.
Almost every one of the 28 inpatients in the internal medicine unit was getting the same long, pink pills.
"Those are our HIV patients," Garoma said.